Wisconsin Department of Administration
Division of Executive Budget & Finance
DOA-6457 (R04/2017) / / Submit completed documents to the State Agency you are invoicing. If you need a contact name and address for agency, email . NOTE: this email address does not accept documents for processing.
STAR Vendor Information
Required sections must be completed or the form will not be processed. Incomplete forms will be returned. All information must be legible.
ALL SECTIONS REQUIRED UNLESS OTHERWISE NOTED
Section 1 – Please specify type of actionEnter the Name of the Agency You Are Invoicing
Select your entity type below and complete the sections indicated:
New Individual or business that provides goods or services to a state agency - complete all sections except section 7.
New City, County, Town, Village, School District, Special Tax District or Technical College – complete all sections.
Note – If you are an INDIVIDUAL that DOES NOT provide goods or services to a state agency (i.e. a grant recipient), you may submit IRS W-9 or W-8 EIC only – you DO NOT need to complete this form. You must include your email address (if you have one) in the requestors name and address area of the W-9 or W-8 EIC.
New Vendor/Business - Attach W-9 or W-8 BEN / Additional Address / Additional Location
For Agency Use Only – Required for Changes
Supplier ID # / Change Contact Person/Information
Location Name / Change of Address – (Provide old address below)
Address ID # / Check All that Apply: Remit to Address 1099 Address
Old Address:
Change of TIN – (also attach IRS W-9 & / Change of Name – (also attach IRS W-9 &
DOA-6459 Change of Tax ID.) / DOA-6458 Change of Vendor Name.)
Section 2 – Please provide Vendor Information
Legal Business or Individual Name (Must match attached W-9 or W-8 ECI):
Business Name, Trade Name, Doing Business as: (If different from above):
Section 3 - Taxpayer Identification Information (Only Provide One Number or Document Will be Returned)
Federal Employer Identification Number: example 00-0000000 / Social Security Number: example 000-00-0000
DUNS No. example 000000000 (Required for Grant Recipients)
Section 4 – Remit To Address (For Checks)
Address: / County:
Address (cont.):
City: / State: / ZIP Code + 4:
Section 5 (Optional) – Additional Address (If more than 2 remit addresses, or 1099 address)
Address: / County:
Address (cont.):
City: / State: / ZIP Code + 4:
DOA-6457 (R05/2016) continued
Name:
Phone: / FAX: / Email:
Additional Contact
Name:
Phone: / FAX: / Email:
Replace Contact (Will be Marked Inactive)
Name of Contact being replaced:
Section 7 – Wisconsin State Agency, Local Government, or District (As Listed Below)
Are you a Wisconsin State Agency, Local Government, or District? / Yes / No
If yes, Please Select One of the Following:
City / County / School District / Special Tax District / Technical College / Town / Village / Other
Entity Name:
Is your entity in the Wisconsin Department of Revenue State Debt Collection Program? (SDC) / Yes / No
Is your entity in the Wisconsin Department of Revenue Tax Refund Intercept Program? (TRIP) / Yes / No
Does your entity receive payments (i.e. shared revenues) from WI Department of Revenue State & Local Finance? / Yes / No
Section 8 – Please Sign and Date (Vendor/Supplier)
Print Name: / Title: / Date:
Authorized Signature:
Contact Email Address: / Contact Phone Number:
Section 9 - For Agency Use Only
Agency Name: / Agency Contact: / Contact Email:
Comments (Optional)
Note: This document contains sensitive information. Sending via non-secure channels, including e-mail and fax can be a potential security risk. Pursuant to 26 USC 6109, the state is required to collect TIN/EIN/Social Security numbers and to use the numbers in its annual report to the IRS the amount the state has paid each vendor.
Submit completed documents to the State Agency to be invoiced.